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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> - (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the'urisdictional area of the an Joaqui Local Health District <br /> H <br /> Business Name (DBA) _ I Address r <br /> aOwner h n t o Address �✓I'� <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. d Emergency Telephone No. <br /> a <br /> ; ZZ <br /> Contractor Licence No. I <br /> L Applicants Name (Print) Title Date 2 ---i <br /> Please check Applicable CG41egory (1-7)and Fill in Ile Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test�Lo ation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Addr s/Locati <br /> Owner <br /> &9C60 Address Q• a �© 1 (� <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD C►9EEPAGE PIT ❑ PACKAGE PLANT <br /> 9 PERMANENT ❑ TEMPORARY ❑ NEW [AREPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> P <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and les and re iati;of �San oaquin Local Health District.. t. ,..,. <br /> APPLICANT'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31" ❑ July 1 &Received BJuly 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 4 DATE DATE REMITTED AMOUNT <br /> Oa <br /> FEE L I <br /> LESS le }� <br /> PRORATION - v} <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No Issuance Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />